INSPIRE
Seven Strategies for Ending Violence Against Children
WHO Library Cataloguing-in-Publication Data:
INSPIRE: seven strategies for ending violence against children.
1.Violence - prevention and control. 2.Child. 3.Stress Disorders, Traumatic. 4.Child Abuse. 5.Program Development.
I.World Health Organization.
ISBN 978 92 4 156535 6 (NLM classification: WA 325)
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The document was designed by Without Violence.
© World Health Organization 2016
Front cover photography credits:
WHO/Christopher Black WHO/Chapal Khasnabis WHO/TDR/Julio Takayama World Bank/Kibae Park/Sipa WHO/Christopher Black WHO/TDR/Julio Takayama WHO/Christopher Black
Printed in Luxembourg
Income and economic strengthening Parent and caregiver support
Education and life skills
Response and support services
Implementation and enforcement of laws
Safe environments Norms and values
INSPIRE
Seven Strategies for Ending Violence Against Children
INSPIRE: Seven strategies for ending violence against children reflects the contributions of technical experts from all core agencies, and many other partners.
Alexander Butchart (WHO) and Susan Hillis (CDC) coordinated and wrote the document, with drafting assistance from Angela Burton, who also edited and proofread the document. Etienne Krug (WHO) provided overall strategic direction.
In addition:
• CDC provided further inputs from James Mercy and Linda Dahlberg;
• End Violence Against Children: The Global Partnership contributed through inputs from Barbara Ammirati, Susan Bissell and David Steven;
• PEPFAR inputs were provided by Janet Saul;
• Together for Girls inputs were provided by Michele Moloney-Kitts and Rebecca Gordon;
• UNICEF provided inputs from Theresa Kilbane, Senior Advisor and Jeanette Trang, UNICEF Child Protection with additional sectoral comments provided by technical staff from Child Protection, Communication for Development, Disability, Early Childhood Development, Education, Gender, Health, Social Inclusion and Data and Analytics.
• UNODC inputs were provided by Anna Giudice Saget, Giulia Melotti, Kobie Mulligan and Sven Pfeiffer;
• USAID inputs were provided by Gretchen Bachmann and John Williamson;
• WHO/PAHO provided further inputs from Betzabe Butron, Alessandra
Guedes, Alison Harvey, Constanza Hege, Berit Kieselbach, Marcelo Korc, and Christopher Mikton, with administrative support from Claire Scheurer;
• World Bank contributions came from Diana Arango and Andres Villaveces.
Thanks also to Kathleen Cravero, Florence Bruce and Brigette Delay of the Oak Foundation for facilitating a civil society organization review of the document and its implementation implications, and to the following organizations for providing comments during this review: African Child Policy Forum; Children and Violence Evaluation Challenge Fund; Child Rights Forum; Child Protection in Crisis Network; End Child Prostitution in Asian Tourism International; End FGM EU Network; Eurochild Network; Girls Not Brides; Global Initiative to End all Corporal Punishment against Children; Promundo; Save the Children; SOS Villages; World Vision.
WHO, on behalf of all participating agencies, would like to thank the United States Centers for Disease Control and Prevention for its generous financial support for the development and publication of this document.
Acknowledgements
CDC: United States Centers for Disease Control and Prevention CRC: Convention on the Rights of the Child
End Violence Against Children: The Global Partnership PAHO: Pan American Health Organization
PEPFAR: President’s Emergency Program for AIDS Relief TfG: Together for Girls
UNICEF: United Nations Children’s Fund
UNODC: United Nations Office on Drugs and Crime
USAID: United States Agency for International Development WHO: World Health Organization
Acronyms
PREFACE 7
INSPIRE an overview 8
INSPIRE the vision 9
INSPIRE the collaboration 9
Ending violence against children is a priority 10
Magnitude of violence against children 12
Defining violence against children 14
Types of violence against children 14
Consequences and costs of violence against children 15 Root causes of violence against children 16 Preventability of violence against children 18
INSPIRE components 20
INSPIRE implementation 26
INSPIRE strategies and approaches 28
Implementation and enforcement of laws 30 Laws banning violent punishment of children by parents,
teachers or other caregivers 32
Laws criminalizing the sexual abuse and exploitation
of children 34
Laws that prevent alcohol misuse 34
Laws limiting youth access to firearms and other weapons 35
Norms and values 36
Changing adherence to restrictive and harmful gender
and social norms 38
Community mobilization programmes 40
Bystander interventions 40
Safe environments 42
Reducing violence by addressing “hotspots” 44
Interrupting the spread of violence 46
Improving the built environment 46
Parent and caregiver support 48
Parent support delivered through home visits 50 Parent training and support delivered in groups in
community settings 52
Parent support and training as part of comprehensive
programmes 53
Contents
Income and economic strengthening 54
Cash transfers 56
Group savings and loans associations combined with
gender norm/equity training 58
Microfinance combined with gender norm/equity training 58
Response and support services 60
Counselling and therapeutic approaches 62 Screening combined with interventions 64 Treatment programmes for juvenile offenders in the
criminal justice system 65
Foster care interventions involving social welfare services 65
Education and life skills 66
Increase enrolment in pre-school, primary
and secondary schools 68
Establish a safe and enabling school environment 68 Improve children’s knowledge about how to protect
themselves from sexual abuse 70
Life and social skills training 71
Adolescent intimate partner violence
prevention programmes 72
INSPIRE: Cross-cutting activities 74
Cross-cutting activity 1: Multisectoral actions and coordination 75 Cross-cutting activity 2: Monitoring and evaluation 78
Monitoring 78
Evaluation 81
Implementation Considerations 82
Build national commitment 84
Assess needs 84
Select interventions 85
Adapt interventions to the local context 86 Prepare national and local government plans of action 86
Estimate costs 88
Identify sustainable sources of financial support 89
Develop and manage human resources 89
Implement, monitor and evaluate 90
CONCLUSION 92
ANNEX A: GLOSSARY 94
REFERENCES 96
Credit: WHO /Christopher Black
Preface
Imagine you woke up this morning to news headlines revealing that scientists had discovered a new disease, and that up to 1 billion children worldwide were
exposed to this disease every year. And that as a result – over the course of their lifetime – these children were at greater risk of mental illnesses and anxiety disorders, chronic diseases such as heart disease, diabetes and cancer, infectious diseases like HIV, and social problems such as crime and drug abuse. If we had such a disease, what would we do?
The truth is we do have such a “disease”. It is violence against children. And one of the first things we would do is draw on the evidence we already have to take immediate, effective and sustainable action to prevent such violence.
Progress in understanding and preventing violence against all children from birth to 18 years is advancing rapidly. Although greater investment is needed to increase our knowledge about how best to prevent violence against children, we already have sufficient evidence to allow us to stop the violence and replace it with safe, stable and nurturing environments in which children can thrive.
This package of seven evidence-based strategies builds on growing evidence that violence against children is preventable, and on a growing public consensus that it will no longer be tolerated. The package will help unify multisectoral efforts to raise awareness that, although levels of violence vary within and between countries, no society is immune as violence against children is everywhere, and it will encourage deeper engagement to prevent it and to treat the harmful consequences when it does occur.
The package is anchored in recognition by the
Convention on the Rights of the Child that all children have the right to be free from all forms of violence. It also responds to the extensive and costly impacts that violence against children has on public health and development. It is an essential tool to help achieve Sustainable Development Goal Target 16.2, which calls for ending all forms of violence against children, and it will be useful to help achieve goals 1, 3, 4, 5, 10, 11
and 16 that target poverty, health, education, gender equality, safe environments and justice.
We have an opportunity and a responsibility to prevent violence, protect children and have a positive impact on a broad range of health, social and economic challenges facing low-, middle- and high-income countries. Violence against children can be prevented if the global community acts now, acts wisely and acts together. This package presents evidence-based ways to do it.
Ending violence against children: an urgent call to action
Michele Moloney-Kitts, Director, Together for Girls
Deborah Birx, US Global AIDS Coordinator, PEPFAR Carissa Etienne, Director, PAHO Susan Bissell,
Director, End Violence Against Children Thomas Frieden, Director, CDC Margaret Chan, Director-General, WHO
Anthony Lake,
Executive Director, UNICEF
Yury Fedotov,
Executive Director, UNODC
Gayle Smith,
Administrator, USAID
Laura Tuck, Vice President for
Sustainable Development, World Bank
INSPIRE Seven Strategies for Ending Violence Against Children 7
INSPIRE:
an overview
INSPIRE is an evidence-based resource for everyone committed to preventing and responding to violence against children
and adolescents – from government to grassroots, and
from civil society to the private sector. It represents a select group of strategies based on the best available evidence to help countries and communities intensify their focus on the
prevention programmes and services with the greatest potential to reduce violence against children. The seven strategies are:
Implementation and enforcement of laws; Norms and values;
Safe environments; Parent and caregiver support; Income and economic strengthening; Response and support services; and Education and life skills. Additionally, INSPIRE includes two
cross-cutting activities that together help connect and strengthen – and assess progress towards – the seven strategies.
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INSPIRE Seven Strategies for Ending Violence Against Children
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INSPIRE: the vision
INSPIRE: the collaboration
INSPIRE’s vision is a world where all governments, with the strong participation of civil society and communities, routinely implement and monitor interventions to prevent and respond to violence against all children and adolescents, and help them reach their full potential.
It reinforces the protections guaranteed in the Convention on the Rights of the Child (CRC), which obliges States Parties to take all appropriate legislative, administrative, social, and educational measures to protect children from all forms of violence while in the care of parents, legal guardians, or any other person who has the care of the child. It reflects the urgent need to address the huge public health and social burden created by violence against children.
INSPIRE aims to help countries and communities achieve key priorities of the 2030 Sustainable
The World Health Organization (WHO) initiated preparation of the INSPIRE package, in collaboration with the United States Centers for Disease Control and Prevention (CDC), End Violence Against Children: The Global Partnership, the Pan American Health Organization (PAHO), the President’s Emergency Program for AIDS Relief (PEPFAR), Together for Girls, the United Nations Children’s Fund (UNICEF), United Nations Office on Drugs and Crime (UNODC), United States Agency for International Development (USAID), and the World Bank (agencies with a long history of galvanizing a consistent, evidence-based approach to preventing violence against children).
Development Goals (SDGs), a new set of goals that UN Member States will use to guide their priorities from 2016-2030. SDG targets addressing violence against children include Target 16.2, “end abuse, exploitation, trafficking and all forms of violence against and torture of children”; SDG Target 5.2, “eliminate all forms of violence against all women and girls in the public and private spheres, including trafficking and sexual and other types of exploitation”, and SDG Target 16.1, “significantly reduce all forms of violence and related death rates everywhere”.
In addition, the seven INSPIRE strategies are supported by and contribute to activities aimed at achieving several other SDG goals that target risk factors for violence against children, including those that address poverty, health, gender equality, education, safe environments and justice, and are therefore important to include in programming to prevent violence against all children.
The seven INSPIRE strategies are most effective when implemented as part of a comprehensive, multisectoral plan that harnesses their synergies, as the strategies are intended to work in combination and reinforce each other. Though stakeholders in many countries are working to eliminate violence against children, their efforts are not always well coordinated and supported, and few are undertaken at a large scale. Coordination mechanisms are therefore essential, as no single sector can deliver the full package of interventions, and no individual government can tackle the growing threats to its children that now transcend national borders.
Efforts to implement the package should therefore encourage cooperation and learning both within and between countries.
INSPIRE Seven Strategies for Ending Violence Against Children 9
Ending Violence Against Children is a Prio rity
Violence against the most vulnerable members of our
society – our children and adolescents – has a devastating impact and leads to a wide range of health and social
problems (Figure 1). Yet much of it is predictable and
preventable through programmes that address its causes and risk factors.
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INSPIRE Seven Strategies for Ending Violence Against Children
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O VI
LE N CE AG AINST C HIL D R
EN
Source: (1)
Figure 1: Potential health consequences of violence against children
Direct effect
Indirect effect due to adoption of high-risk behaviour
Chronic lung disease Unintended
and adolescent pregnancy Death
(including foetal death)
Depression anxietyand
Physical inactivity Internal
injury
Fractures Head
injury
Burns
Alcohol and drugs
Unsafe sexual practices
Multiple partners Pregnancy
complications
Stroke
Heart disease Obesity
HIV
STDs
Alcohol
Smoking Post
Traumatic Stress Disorder
Assault Suicide
Cancer Diabetes
Communicable disease and risk behaviours
Injury
is dbleicaunNonmmco
seea
and
risk b
av eh rs iou at M
na er nd l a
chi
ld health
Mental health problems
Magnitude of violence against children
An analysis of nationally representative survey data on the prevalence of violence against children in 96 countries estimates that 1 billion children globally – over half of all children aged 2–17 years – have experienced emotional, physical or sexual violence in the past year (2).
Despite its high prevalence, violence against children is often hidden, unseen or under-reported. Its hidden nature is well documented (3) – for example, a meta-analysis of global data finds self-reported child sexual abuse 30 times higher and physical abuse 75 times higher than official reports would suggest (4, 5).
Girls are particularly vulnerable to sexual violence. For example, the lifetime prevalence of childhood sexual abuse is 18% for girls, compared to 8% for boys (4). Perpetrators of sexual violence against girls are predominantly males. Girls are also more likely to experience intimate partner violence (sexual and/or physical); rape by acquaintances or strangers; child or early/forced marriage; trafficking for the purposes of sexual exploitation and child labour, and genital mutilation/cutting. Such violence occurs in many settings, including those where girls should be safe and nurtured — at home; travelling to, from and within school;
in their communities; and in situations of humanitarian emergency, displacement, or post-conflict settings.
Boys are more likely to be both victims and perpetrators of homicide, which commonly involves weapons such as firearms and knives (7).
Globally, nearly one in three adolescent girls aged 15 to 19 (84 million) have been the victims of emotional, physical and/or sexual violence perpetrated by their husbands or partners (6).
INSPIRE Seven Strategies for Ending Violence Against Children
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Homicide is among the top five causes of death in adolescents, with boys comprising over 80% of victims and perpetrators. In addition, for every homicide there are hundreds of predominantly male victims of youth violence who sustain injuries as a result. Boys are also more likely to be the victims and perpetrators in fights and assaults (7).
Given the high rates at which girls and boys experience violence, this paints an alarming picture of the extent to which children live with the impact of violence, in the absence of support or services. In many countries, the true magnitude of the problem is vastly underestimated, partly because prevalence estimates come from administrative data used by health or justice systems and not from national survey data, and partly because of the widespread beliefs that lead people – including children – to see violence as a norm rather than a problem demanding attention.
Furthermore, girls and boys who do report such violence are often stigmatized, or not believed, and no action is taken. Though violence may be hidden, its consequences eventually surface (8), creating a pervasive, enduring and costly toll for children and adults, communities and nations.
In 2012, homicide claimed the lives of about 95 000 children and adolescents under the age of 20 years – almost one in five of all homicide victims that year (6).
INSPIRE Seven Strategies for Ending Violence Against Children 13
This package defines children as all persons aged under 18 years, and therefore defines violence against children as violence against all persons aged under 18 years. According to WHO, violence is “the intentional use of physical force or power, threatened or actual, against oneself, another person, or against a group or community, which either results in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment, or deprivation”
(9). Violence thus includes more than acts leading to physical harm. Its consequences are far wider than deaths and injuries, and can include communicable and noncommunicable disease, psychological harm, risky behaviours, educational and occupational underachievement and involvement in crime.
Most violence against children involves at least one of six main types of interpersonal violencea that tend to occur at different stages in a child’s development (Figure 2) (9):
• Maltreatment (including violent punishment) involves physical, sexual and psychological/emotional violence;
and neglect of infants, children and adolescents by parents, caregivers and other authority figures, most often in the home but also in settings such as schools and orphanages.
• Bullying (including cyber-bullying) is unwanted aggressive behaviour by another child or group of children who are neither siblings nor in a romantic relationship with the victim. It involves repeated physical, psychological or social harm, and often takes place in schools and other settings where children gather, and online.
• Youth violence is concentrated among those aged 10–29 years, occurs most often in community settings between acquaintances and strangers, includes physical assault with weapons (such as guns and knives) or without weapons, and may involve gang violence.
• Intimate partner violence (or domestic violence) involves violence by an intimate partner or ex-partner.
Although males can also be victims, intimate partner violence disproportionately affects females. It
commonly occurs against girls within child and early/
forced marriages. Among romantically involved but unmarried adolescents it is sometimes called “dating violence”.
• Sexual violence includes non-consensual completed or attempted sexual contact; non-consensual acts of a sexual nature not involving contact (such as voyeurism or sexual harassment); acts of sexual trafficking committed against someone who is unable to consent or refuse; and online exploitation.
• Emotional or psychological violence and witnessing violence includes restricting a child’s movements, denigration, ridicule, threats and intimidation,
discrimination, rejection and other non-physical forms of hostile treatment. Witnessing violence can involve forcing a child to observe an act of violence, or the incidental witnessing of violence between two or more other persons.
When directed against girls or boys because of their biological sex or gender identity, any of these types of violence can also constitute gender-based violence.
a Children can also be affected by two other types of violence that are beyond the scope of this package: self-directed violence, including suicidal behaviour and self-abuse, and collective violence such as war and terrorism, committed by larger groups of people. In addition, INSPIRE does not explicitly consider human trafficking, a risk factor that in some settings may increase the likelihood of violence against children. Lastly, the package does not cover female genital mutilation/cutting, for which consolidated guidance already exists (e.g. http://www.who.int/reproductivehealth/topics/fgm/management-health-complications-fgm/en/ and http://www.unfpa.org/sites/default/files/pub-pdf/
who_rhr_10-9_en.pdf).
Defining violence against children
Types of violence against children
Figure 2: Type of violence by age group affected.
‹5 5-10 11-17 18+
Child maltreatment
Bullying
Youth violence
Intimate partner violence Sexual violence
Emotional or psychological violence and witnessing violence
Consequences and costs
of violence against children
The immediate and long-term public health consequences and economic costs of violence against children undermine investments in education, health, and child well-being, and erode the productive capacity of future generations. Exposure to violence at an early age can impair brain development and damage other parts of the nervous system, as well as the endocrine, circulatory, musculoskeletal, reproductive, respiratory and immune systems, with lifelong consequences (8). Strong evidence shows that violence in childhood increases the risks of injury; HIV and other sexually transmitted infections; mental health problems; delayed cognitive development; poor school performance and dropout; early pregnancy; reproductive health problems; and communicable and noncommunicable diseases (10–30).
The economic impact of violence against children is also substantial, as shown by data from countries and regions where the financial toll of such violence has been estimated. In the USA alone, the total lifetime economic burden associated with new cases of child maltreatment occurring in one year was US$ 124 billion in 2008, and costs increase if other types of violence, such as youth violence, are considered (31, 32). In the East Asia and Pacific region it is estimated that the economic costs of just a few of the health consequences of child maltreatment were equivalent to between 1.4% and 2.5% of the region’s annual GDP (33).
INSPIRE Seven Strategies for Ending Violence Against Children 15
A key factor that makes children and adolescents, particularly girls, vulnerable to violence (and increases the likelihood that boys and men perpetrate such violence) is social tolerance of both victimization of girls and perpetration by boys and men. Often this abuse or exploitation is perceived as normal and beyond the control of communities which, alongside shame, fear and the belief that no one can help, results in low levels of reporting to authorities. In addition, victims are often blamed for the violence they experience. This social tolerance of violence in general, and intimate partner and sexual violence in particular, stems from the low status of women and children in many societies, and cultural norms surrounding gender and masculinity. Therefore, changing gender norms relating to male entitlement over girls and women’s bodies – and control over their behaviour – is a critical strategy to achieve gender equality, reduce violence aimed at girls, shape prevention activities and address specific care and support needs.
Violence is also rooted in a number of other social, economic and cultural factors that impact communities, families, relationships, and the manner in which children experience their daily lives. The social ecological model depicts this interplay of individual, relationship, community, and societal factors (Figure 3) (9).
• Individual-level risk factors include biological and personal history aspects such as sex, age, education, income, disability, impaired brain and cognitive development, psychological disorders, harmful use of alcohol, drug abuse, and a history of aggression or maltreatment.
• Close-relationship level risk factors include a lack of emotional bonding, poor parenting practices, family dysfunction and separation, associating with delinquent peers, children witnessing violence against their mother or stepmother, and early or forced marriage.
• Community-level risk factors include how the characteristics of settings such as schools, workplaces and neighbourhoods increase the risk of violence. These include poverty, high population density, transient populations, low social cohesion, unsafe physical environments, high crime rates and the existence of a local drug trade.
• Society-level risk factors include legal and social norms that create a climate in which violence is encouraged or normalized. These also include health, economic, educational and social policies that maintain economic, gender or social inequalities; absent or inadequate social protection; social fragility owing to conflict, post-conflict or natural disaster; weak governance and poor law enforcement.
Root causes of violence against children
INSPIRE Seven Strategies for Ending Violence Against Children
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The interaction between factors at the different levels is just as important as the influence of factors within a single level (9). For example, longitudinal studies suggest that complications associated with pregnancy and delivery – perhaps because they lead to neurological damage and psychological or personality disorder (individual risk factors) – seem to predict child maltreatment and youth violence mainly when they occur in combination with other problems within the family, such as poor parenting practices (34). Several other common risk factors – such as family dysfunction and low social cohesion within the community – place some children at much greater risk than others. And, as humanitarian crises including war, mass refugee movements, economic migration, climate disasters and disease outbreaks proliferate, more children than ever are becoming vulnerable to violence of all forms.
Though programmes and policies often address different forms of violence in isolation, it is important to recognize that the different forms are connected, as they share common root causes. Because they share common causes, they often occur together, and one can lead to another. For instance, being a victim of child maltreatment can increase the risk in later life of becoming a victim or perpetrator of sexual violence, youth violence, self-directed violence and intimate partner violence. Children who witness intimate partner violence against their mother or stepmother are also more likely to experience such violence in later life – both as victims and as perpetrators (35–36). Thus, programmes that effectively address root causes have high potential for reducing multiple forms of violence against children.
• Rapid social change
• Economic inequality
• Gender inequality
• Policies that
increase inequalities
• Poverty
• Weak economic safety nets
• Legal and cultural norms that support violence
• Inappropriate access to firearms
• Fragility due to conflict/post-conflict or natural disaster
• Concentrated poverty
• High crime levels
• High residential mobility
• High unemployment
• Local illicit drug trade
• Weak institutional policies
• Inadequate victim care services
• Physical environment situational factors
• Poor parenting practices
• Marital discord
• Violent parental conflict
• Early and forced marriage
• Low socio-economic household status
• Friends that engage in violence
• Sex
• Age
• Income
• Education
• Disability
• Victim of child maltreatment
• History of violent behaviour
• Alcohol/substance abuse
• Psychological/
personality disorder Figure 3: Social ecological model for understanding and preventing violence against children
SOCIETAL COMMUNITY RELATIONSHIP INDIVIDUAL
Source: (9)
INSPIRE Seven Strategies for Ending Violence Against Children 17
Violence against children is a multifaceted problem with causes at the individual, close relationship, community, and societal levels, so it must be simultaneously confronted on several different levels. The social ecological model serves a dual purpose in this regard, as each level in the model represents a dimension where both risks and opportunities for prevention co-exist.
Dealing with violence against children therefore involves implementing measures to:
• create safe, sustainable and nurturing family environments, and provide specialized help and support for families at risk of violence;
• modify unsafe environments through physical changes;
• reduce risk factors in public spaces (e.g. schools, places where young people gather) to reduce the threat of violence;
• address gender inequities in relationships, the home, school, the workplace etc.;
• change the cultural attitudes and practices that support the use of violence;
• ensure legal frameworks prohibit all forms of violence against children and limit youth access to harmful products, such as alcohol and
firearms;
• provide access to quality response services for children affected by violence;
• eliminate the cultural, social and economic inequalities that contribute to violence, close the wealth gap and ensure equitable access to goods, services and opportunities; and
• coordinate the actions of the multiple sectors that have role to play in preventing and responding to violence against children.
As described in the following sections, the seven INSPIRE strategies cover all of these key entry points for preventing and responding to violence against children and adolescents.
Preventability of violence against children
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Credit: WHO/Chapal Khasnabis
INSPIRE
components
The INSPIRE package includes seven strategies that together provide an overarching framework for ending violence against children. Each strategy is accompanied by a key objective ; the rationale for the strategy; SDG Targets other than 16.2 which it contributes to and is supported by; its potential effects on preventing
violence against children; specific approaches (including programmes, practices and policies), that advance the strategy; and evidence supporting these approaches.
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The seven strategies were selected based on a strong convergence in the research-based guidance already published by INSPIRE’s participating agencies.
They address risk and protective factors for violence against children at all four interrelated levels of risk (individual, relationship, community, society), and most have been shown to have preventive effects across several different types of violence, as well as benefits in areas such as mental health, education and crime reduction. Additionally, INSPIRE includes two cross-cutting activities that together help connect and strengthen – and assess progress towards – the seven strategies.
Credit: Kibae Park/Sipa - World Bank
Each INSPIRE strategy contains one or more evidence-based approaches (Table 1). The examples of approaches do not form a comprehensive list of evidence-based policies, programmes and practices for each strategy, but rather illustrate models that are shown to reduce the likelihood of becoming a victim or perpetrator of violence against children; modify risk factors for such violence; or reduce its immediate and long-term consequences. In practice, the effectiveness of the
strategies and approaches included in INSPIRE will depend on the quality and characteristics of their implementation. The model interventions represent either effective, promising or prudent practice.
Criteria for inclusion
Credit: WHO /Christopher Black
Effective interventions meet at least one of the following criteria:
• at least two high- or moderate-quality impact studies using randomized controlled trial and/or high- quality quasi-experimental designs have found favourable, statistically significant impacts in one or more violence against children domains (maltreatment, bullying, youth violence, intimate partner violenceb and sexual violence);
• the intervention is deemed recommended based on high-quality meta-analyses and systematic reviews of findings from evaluations of multiple interventions.
Promising interventions are those where:
• at least one high- or moderate-quality impact study using a randomized controlled trial and/or high- quality quasi-experimental designs has found favourable, statistically significant impacts in one or more violence against children domains (maltreatment, bullying, youth violence, intimate partner violence, and sexual violence); or
• at least one high- or moderate-quality impact study using randomized controlled trial and/or a high- quality quasi-experimental designs has found favourable, statistically significant impacts for one or more risk or protective factors for violence against children (such as educational attainment, positive parenting skills, communication between parents and children about effective strategies for avoiding exposure to violence, increased parental supervision).
Prudent practice components of the technical package meet at least one of the following criteria:
• global treaties or resolutions have determined the intervention as critical for reducing violence against children;
• the intervention has been demonstrated by qualitative or observational studies as effective in reducing violence against children.
The two cross-cutting components – Multisectoral actions and coordination, and Monitoring and evaluation – are essential requirements for any evidence-based, multisectoral intervention (37).
Criteria for model interventions
b Evidence suggests that children’s exposure to violence against their mothers/stepmothers may in some cases lead to increased risk of involvement in violence later in life (e.g.
35-36). Therefore, reducing intimate partner violence is an important goal in itself, and a means of reducing violence against children.
The INSPIRE strategies were as far as possible chosen to represent interventions that have been implemented and evaluated in low-
resource settings. Where drawn from high-income settings, examples of interventions that appear especially effective in reducing violence against children – and also likely to succeed across various cultural settings – were selected. The INSPIRE package provides an opportunity to increase the number of studies of the effectiveness of the seven strategies in settings where currently there are relatively few such studies. It is therefore anticipated that INSPIRE will be regularly updated as new evidence emerges.
INSPIRE Seven Strategies for Ending Violence Against Children 23
Strategy
Income and economic strengthening Norms and values
Safe
environments
Parent and caregiver support
Implementation and
enforcement of laws
Response and support services
Education and life skills
Multisectoral actions and coordination
Monitoring and evaluation
Approach Sectors Cross-cutting
activities
• Increase enrolment in pre-school, primary and secondary schools
• Establish a safe and enabling school environment
• Improve children’s knowledge about sexual abuse and how to protect themselves against it
• Life and social skills training
• Adolescent intimate partner violence prevention programmes
• Counselling and therapeutic approaches
• Screening combined with interventions
• Treatment programmes for juvenile offenders in the criminal justice system
• Foster care interventions involving social welfare services
• Laws banning violent punishment of children by parents, teachers or other caregivers
• Laws criminalizing sexual abuse and exploitation of children
• Laws that prevent alcohol misuse
• Laws limiting youth access to firearms and other weapons
• Delivered through home visits
• Delivered in groups in community settings
• Delivered through comprehensive programmes
• Reducing violence by addressing
“hotspots”
• Interrupting the spread of violence
• Improving the built environment
• Changing adherence to restrictive and harmful gender and social norms
• Community mobilization programmes
• Bystander interventions
• Cash transfers
• Group saving and loans combined with gender equity training
• Microfinance combined with gender norm training
Finance, Labour Health, Education, Social Welfare Interior, Planning
Social Welfare, Health Justice
Health, Justice, Social Welfare
Education
Table 1: INSPIRE strategies, approaches and sectors for preventing and responding to violence against children aged 0–18 years
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Credit: WHO/TDR /Julio Takayama
c These INSPIRE support materials are being developed. It is hoped to release the list of indicators before the end of 2016, and a set of implementation manuals (one for INSPIRE overall, and one per strategy), and research manuals in the course of 2017.
INSPIRE
implementation
The focus of INSPIRE is on what countries can do to prevent and respond to violence against children.
Subsequent INSPIRE materials will focus in detail on how to implement the package contents, including indicators for monitoring both the implementation and impact of the seven strategies.
cIn the meantime, INSPIRE: Seven Strategies for Ending Violence Against Children concludes with general guidance on implementation considerations that can be used to help catalyse progress towards ending violence against children.
IV
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All seven INSPIRE strategies could be applied in settings affected by conflict or natural disaster, and the package includes several interventions shown to be effective in such situations. However, as with strategies that address other societal problems such as smoking, drug use and
excessive alcohol use, mental health, crime, and road traffic injuries, the feasibility of successfully implementing them will vary according to the strategy and the context. In principle, because they do not depend upon intact social systems and functioning governance structures, interventions delivered through self-contained programmes
can be delivered in any setting. These include, for example, parenting programmes, life skills training programmes, and services for victims of violence. By contrast, interventions involving the enforcement of laws by functioning police and justice systems will be difficult to implement where conflict or natural disaster have destroyed or severely eroded these structures.
Applicability of INSPIRE strategies in conflict, post-conflict and other humanitarian settings
INSPIRE Seven Strategies for Ending Violence Against Children 27
INSPIRE
strategies and approaches
V
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Education and life skills
Response and support services Safe environments
Parent and caregiver support Norms and values
Implementation and enforcement of laws
Income and economic strengthening
66 60 42
48 36 30
54
Implementation and enforcement of laws
Objective : Ensure the implementation and enforcement of laws to prevent violent behaviours, reduce excessive alcohol use, and limit youth access to firearms and other weapons
N S P I R E
I
Developing and strengthening legal protections and policies for children and youth, in conjunction with the means to enforce these protections, is a prudent step in preventing violence against children. Laws that prohibit behaviours such as violent punishment and child sexual abuse, are useful in several ways. First, they show society that violent behaviour is wrong, and can therefore help eradicate prevailing norms that tolerate it. Second, they hold perpetrators accountable for their actions. Third, laws and policies can also be useful in reducing exposure to key risk factors for violence against children, by reducing alcohol misuse and limiting youth access to firearms and weapons.
This strategy contributes to and is supported by
activities to achieve SDG Targets 3.5, 5.c and 16.3:
• 3.5 Strengthen the prevention and treatment of substance abuse, including narcotic drug abuse and harmful use of alcohol.
• 5.c Adopt and strengthen sound policies and enforceable legislation for the promotion of gender equality and the empowerment of all women and girls at all levels.
• 16.3 Promote the rule of law at national and international levels and ensure equal access to justice for all.
• Reductions in physical violence towards children by parents, caregivers and authority figures
• Reductions in sexual abuse of children, including forced or pressured sex, unwanted attempted sex, and unwanted sexual touching
• Reductions in sexual exploitation of children including trafficking, pornography and prostitution
• Reductions in excessive alcohol consumption and binge drinking
• Reductions in firearm-related deaths and non-fatal injuries
• Increases in social norms and attitudes that protect against the use of violent punishment against children
• Increases in social norms and attitudes that protect against the sexual abuse and exploitation of children
• Increases in social norms and attitudes that support gender equality
Rationale:
Potential effects of implementing and enforcing laws on reducing violence against children:
Implementation and enforcement of laws
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Implementation and enforcement of laws
Approaches
This strategy encompasses two sets of laws. The first set comprises laws or measures that States Parties are obliged to implement under the UN Convention on the Rights of the Child (CRC), which requires States Parties to take all appropriate legislative, administrative, social, and educational measures to protect children from all forms of violence while in the care of parents, legal guardians, or any other person who has the care of the child (38). The CRC also contains particular obligations concerning the protection of children from cruel, inhuman or degrading treatment or punishment and capital punishment, as well as sexual abuse and exploitation.
The second set of laws are those limiting youth access to and misuse of alcohol and firearms, thereby
addressing key risk factors for being a victim or perpetrator of violence against children. Additionally, refugee law, and laws criminalizing child marriage, forced labour, trafficking, child pornography and harmful practices may also contribute to reducing violence against children.
Evidence: Observational studies suggest these laws can reduce the use of violent punishment against children, deepen understanding of the negative effects on children of violent punishment, and change attitudes towards the use of such punishment (39–41). Findings from a study comparing five European countries – three of which had bans on corporal punishment and two of which did not – report that nearly all forms of corporal punishment were used less commonly in countries with legal bans than in those without such bans (42). Furthermore, acceptance of corporal punishment was lower in countries with bans on corporal punishment (43). A systematic review also showed that legislative restrictions on corporal punishment in 24 countries were closely associated with decreased support for and use of corporal punishment as a child discipline approach (43). By 2016, nearly 50 countries had prohibited all violent punishment of children, and another 52 had committed to doing so (44).
Laws banning violent punishment of children by parents, teachers or other caregivers
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Implementation and enforcement of laws
Anti-corporal punishment law and campaign (Sweden)
In 1979, the Swedish Parliament adopted an amendment to the Children and Parents Code that banned all forms of physical punishment or other emotionally abusive treatment of children.
This made Sweden the first country in the world to explicitly prohibit parents from using corporal punishment or any other humiliating treatment in child rearing.
While the Children and Parents Code does not contain penalties, actions that meet the legal criteria of assault are subject to the Penal Code.
This states that a person who inflicts bodily injury, illness or pain upon another, or renders him or her powerless or in a similar helpless state, shall be sentenced for assault to imprisonment for a maximum of two years. If the crime is less serious, perpetrators are fined or imprisoned for up to
six months. If the offence is found to be especially serious, a sentence of up to 10 years may be imposed (45).
Effectively, children are given the same rights as adults to protect them from violent and other humiliating treatment. The legislative change, coupled with a national education campaign, was the result of a decades-long process that included the banning of corporal punishment in schools. The Swedish effort has had a significant, measurable impact on the lives of children: the number of children who have been hit has decreased from 90% to about 10% over a 35- year period (45). Among parents, public support for corporal punishment also decreased from over half to barely 10% (45).
INSPIRE Seven Strategies for Ending Violence Against Children 33
Implementation and enforcement of laws
Evidence: The CRC sets forth principles about sexual abuse and
exploitation that can be incorporated or reflected in domestic laws. Most countries have such laws in place, though their strength varies depending on the legal definition of a child, what constitutes child sexual abuse and exploitation, and the extent to which the laws are enforced. For example, though virtually all countries have laws prohibiting statutory rape, such laws are fully enforced in less than two-thirds of countries. Enforcement is even less common for laws against contact sexual violence without rape and non-contact sexual violence (1).
Evidence: Heavy alcohol consumption is a clearly established risk factor for most forms of violence against and among children, including the perpetration of child maltreatment, physical and sexual violence among male and female adolescents, and intimate partner violence (34). Globally, 17% of male and 6% of female adolescents aged 15–19 years are estimated to be heavy drinkers (i.e. consumed 60 grams or more of pure alcohol at least once in the past month) (46). Laws and policies limiting children’s access to and adults’ and children’s misuse of alcohol can therefore play an important role in preventing violence against children.
A review of scientific studies published between 1950 and 2015 concluded that increasing the price of alcohol, restricting the days of sales
and limiting the clustering of alcohol outlets are all associated with substantial reductions in the perpetration of interpersonal violence (47). The review further notes that even modest policy changes, such as 1% increases in alcohol price, one-hour changes to closing times, and limiting alcohol outlet densities substantially reduce violence.
Furthermore, minimum-age purchase limits are effective in reducing alcohol consumption among youth (48), and setting age limits that are higher is more likely to deter youth drinking than younger age limits (49).
Most countries’ laws set the legal age limit for the purchase of alcohol at 18 years, although there is considerable variation in the extent to which such limits are enforced (46).
Laws criminalizing the sexual abuse and exploitation of children
Laws that prevent alcohol misuse
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Implementation and enforcement of laws
Evidence: The minimum legal age to use, possess and purchase a firearm varies from country to country, although most set 18 years as the minimum. A recent systematic review (50) of interventions designed to reduce illegal possession and carrying found that directed police patrols focusing on illegal gun carrying can prevent gun crimes (including murders, shootings, gun robberies and gun assaults).
Other interventions such as Child Access Prevention (CAP) laws (which hold the gun owner responsible if a child gains access to a gun that is not securely stored) in the USA are associated with reductions in firearm- related injuries. For example, a longitudinal study based on data from 11 US states (seven of which passed CAP laws between 1988 and 2003) found CAP laws were associated with lowering levels of non-fatal firearm injuries among children under the age of 18. However, most of these were unintentional injuries, and the findings related to youth homicide and other violence outcomes were inconsistent and weak (51).
Evidence for other laws and policies around the world (e.g. zero- tolerance policies in schools; licensing requirements; laws to disrupt the illegal circulation of weapons within and between communities) is mixed (52). But, a recent South African study found that stricter licensing and reduced circulation of firearms accounted for an estimated 4585 lives saved across five major cities between 2001–2005 (with some of the steepest reductions occurring among 15–29-year-old males) (53).
Strategies addressing youth access to firearms therefore show promise, although more research is needed to determine the most effective ways to prevent illegal possession, carrying, and use among youth.
Laws limiting youth access to firearms and other weapons
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Norms
and values
Objective : Strengthen norms and values that support non-violent, respectful, nurturing, positive and gender equitable relationships for all children and adolescents
I N S P I R E
Changing attitudes and norms in society is an important part of preventing violence against
children (6). Doing so often requires modifying deeply ingrained social and cultural norms and behaviours – in particular, the idea that some forms of violence are not only normal, but sometimes justifiable (54).
Examples include teachers hitting children because violent punishment is seen as legitimate; girls forced to have sex because of the sexual entitlement felt by boys and men; accepting child marriage or wife- beating as normal; male peers coercing younger boys into gang violence as a “rite of passage”; and girls and boys not reporting violence because of fear of stigma and shame.
A strategy to change attitudes and social norms is therefore a key part of the INSPIRE package, and, while hard to evaluate, norm-change activities at community or small-group level appear to be most effective when combined with other elements such as legislation or life-skills training.
This strategy contributes to and is supported by activities to achieve SDG Targets 4.7 and 5.1:
• 4.7 By 2030, ensure that all learners acquire the knowledge and skills needed to promote sustainable development, including, among others, through education for sustainable development and
sustainable lifestyles, human rights, gender equality, promotion of a culture of peace and non-violence, global citizenship and appreciation of cultural diversity and of culture’s contribution to sustainable development.
• 5.1 End all forms of discrimination against all women and girls everywhere.
• Reduced acceptance of violence against women and children
• Reductions in early and forced marriage
• More favourable beliefs towards gender equity and gender-equitable division of labour
• More favourable attitudes to non-violent approaches to parental discipline
• Greater recognition of what constitutes abusive behaviour towards intimate partners and children
• Increased bystander intervention to prevent violence against children and intimate partners
• Reductions in physical or sexual violence by a parent or intimate partner
Rationale:
Potential effects of norms and value change on reducing violence against children include:
Norms and values
INSPIRE Seven Strategies for Ending Violence Against Children 37
Approaches
Evaluations of programmes and policies that modify potentially harmful parenting and gender norms find that promising approaches include changing adherence to harmful gender and social norms, community mobilization programmes, and bystander interventions. When supported by mass media/social mobilization campaigns and supportive services, these approaches have successfully encouraged greater reporting of violence and the enactment of new laws and policies that make certain forms of violence a punishable offence (54).
Evidence: Small group programmes targeting adult men and women and adolescent girls and boys report a number of significant violence prevention outcomes (55–59). Males in India participating in Yaari-Dosti were found to have 20%–30% decreases in intimate partner violence perpetration (59), and males in the USA programme Coaching Boys Into Men reported 38% fewer incidents of physical or sexual intimate partner violence perpetration 24 months after the intervention (59,60).
Other significant outcomes of this programme, which provides high school athletics coaches with the resources they need to promote
respectful behaviour among players and help prevent relationship abuse, harassment and sexual assault, included increases in bystander intention to intervene. The programme has been implemented in communities across the USA, and in India and South Africa.
In Nepal, the Choices curriculum aims to stimulate discussions between 10–14-year-old boys and girls in which they can reflect on topics relating to power and gender. A case-control study suggested that participation in Choices broadened children’s perception of gender roles, including the role of women as wage earners and men as nurturers, and may have helped participants recognize that sexual harassment and teasing boys who step out of the “gender box” is inappropriate (61).
Norms and values
Changing adherence to restrictive and harmful gender and social norms
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Ending child marriage:
a study of 23 programmes
Child marriage is a risk factor for intimate partner violence against girls and women, death in childbirth and non-fatal pregnancy-related complications (62), infant mortality (63) and low birth-weight (64). Child marriage disproportionately affects young girls, who are much more likely to be married as children than young boys (65, 66).
Worldwide it is estimated that over 60 million women aged 20–24 years were married before they reached the age of 18 years (67). The extent of child marriage varies substantially between regions, with the highest rates found in West Africa, followed by South Asia, North Africa and the Middle East, and Latin America (68).
A 2011 review by the International Center for Research on Women (69) pointed to an increase in the number of interventions targeting child marriage during the past decade, but noted that very few were systematically evaluated. Based on analysis of 23 programmes that had some form of evaluation, the review found that few
programmes focused exclusively on child marriage, which for most programmes was included along with goals for achieving other health, welfare
or empowerment outcomes for adolescents and youth. Evaluated child marriage programmes were found to be heavily concentrated in South Asia, with Bangladesh and India topping the list. Countries in Africa and the Middle East, such as Ethiopia and Egypt, also contributed to the evidence base (70).
Programmes have generally deployed one or more of five core strategies to prevent child marriage:
empowering girls with information, skills and support networks; educating and mobilizing parents and community members; enhancing the accessibility and quality of formal schooling for girls; offering economic support and incentives for girls and their families;
and fostering an enabling legal and policy framework.
The review found that most evaluation designs were weak, but that the strongest, most consistent results in reducing child marriage were evident for a subset of programmes promoting information, skills and networks for girls in combination with community mobilization (69).
Norms and values
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Evidence: SASA! (Kiswahili for “Now!”) in Uganda is a strong example of how norm change can be mobilized through community-based approaches to preventing violence against women(71). In communities where men and women participated in the programme, women
experienced 52% less physical intimate partner violence, and the social acceptance of violence fell. Among women who did experience intimate partner violence, appropriate community responses more than doubled, and a follow-up study suggested there was a triple benefit for children (see Box 1).
Evidence: Experimental evaluations showed that programmes such as Bringing in the Bystander and The University of Kentucky’s (USA) Green Dot violence prevention programme empowered young people to intervene and prevent violence against dating partners and acquaintances (76, 77).
Interpersonal violence victimization rates (measured in the past academic year) were 17% lower among students attending the intervention (46%), relative to comparison campuses (56%). Violence rates were lower on intervention versus comparison campuses for sexual victimization, sexual harassment, stalking, and psychological intimate partner violence (78).
Of note, both male and female students attending colleges with a Green Dot programme reported lower victimization, and males reported lower perpetration rates, compared to colleges without the programme.
In South Africa, the Soul City intervention to teach communities about domestic violence through ‘edutainment’ reached 86%, 25% and 65%
of audiences through television, booklets and radio, respectively. The evaluation also found a demonstrable link between public exposure to Soul City’s fourth series, which focused on domestic violence, and increased knowledge of support services – 41% of respondents reported awareness of a helpline set up by Soul City (74). Attitude shifts were also associated with the intervention, with a 10% increase in respondents disagreeing that domestic violence was a private affair. The intervention also developed a multimedia project aimed at children aged 8–12 years called Soul Buddyz, which offered television, radio and interactive content conveying potentially life-saving messages for the children before they become sexually active, with strategies for dealing with bullying, racism, violence, sex and HIV/AIDS (75).
Community mobilization programmes
Bystander interventions Norms and values
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